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The business environment in which we practice is changing. Social and medical problems of women continue for large numbers of our population. The obstetrician-gynecologist as the primary care provider for women must be active as the patient's advocate in the areas of sex education, contraceptive counseling, teenage pregnancy, domestic violence, healthy lifestyles, and decisions regarding appropriate health care.

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Concurrent and retrospective analyses of drug use may be needed to ensure that formulary conversions are achieving the desired results. The department of pharmaceutical services at Botsford General Hospital, a 325-bed community teaching hospital in Farmington Hills, Mich., analyzed the impact of a formulary H2-receptor antagonist conversion and demonstrated that quality of care was maintained with significant cost savings achieved.

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During a 14-month period of using a long-term absorbable suture (No. 1 Maxon), 402 patients were entered into a prospective, randomized trial of fascial closure. Patients were randomized between a continuous closure (201 patients) and an interrupted en bloc (201 patients) technique. Each patient was subjected to a preoperative and intraoperative protocol for wound management. There were no acute wound failures. Wound infection rates and risk of hernia were not apparently affected by closure technique.

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The comparative efficacy of single-dose antibiotic prophylaxis was retrospectively evaluated in 116 patients undergoing extended pelvic surgical procedures with curative intent. During the 24-month period, other important variables such as surgeon's experience, duration of preoperative hospitalization, preoperative preparation, method of hair removal, suture type, suture size, use of drains, use of cautery, and abdominal closure were controlled. The overall surgical site infection rate was 4.3% after radical hysterectomy with lymphadenectomy and 4.5% after total hysterectomy with lymphadenectomy. In this clinical situation the use of a single dose of antibiotic prophylaxis theoretically decreases cost and patient exposure and appears to be as efficacious as a multiple-dose regimen.

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A two-stage approach to the surgical management of acute Budd-Chiari syndrome complicated by inferior vena caval obstruction was advocated by our group in 1984. This entailed initial hepatic decompression by suprahepatic, mesoatrial shunt, with subsequent takedown of the mesoatrial shunt combined with conversion to a short infrahepatic, portacaval shunt. We report herein the late follow-up results for two patients managed in this manner. While both patients are alive and doing well, both of the courses have been complicated by stenosis of the inferior vena cava. The cause is unclear but probably relates to fibrosis at the hepatic venous orifices. Management was by percutaneous balloon dilation, which relieved the recurrent hepatic congestion. This cautions others considering this approach to provide careful longitudinal follow-up study for such patients.

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Plasma and tissue levels of cefotetan after a single-gram intravenous preoperative dose were measured. Levels were high in some tissues (parametrium, fascia) but quite low in others (subcutaneous fat). The implications as to the prophylactic effectiveness of this drug are addressed.

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A prospective randomized study of 90 patients undergoing hysterectomy who received a single 1 gm dose of cefotetan and multiple 2 gm doses of cefoxitin was completed. An overall infection rate of 1.2% was recorded. Bacteriologic and clinical success rates were not different between antibiotics.

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The purpose of the project was to develop and implement a method whereby unused intravenous preparations could be redispensed for a subsequent dose to another patient. Even if the stability and sterility of the solution can be assured, since the admixture has left the controls of the Pharmacy, it cannot be reused because of the possibility that further additions have been made. If the pharmacy could assure that an admixture has not been altered in any way, it could be redispensed. Tamper-Proof Safety Caps have been placed over the additive port of Viaflex minibags after preparation, thereby rendering it impossible for further additions to be made, and therefore these admixtures can be reused for a different patient. The Department of Pharmaceutical Services has begun to recycle admixtures and has experienced an annual cost savings in 1981 of $64,512. The cost of the program for the protective caps was $17,810. This cost savings has been accomplished without further additions to the staff.

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We prospectively examined the accuracy of Gram-stained sputum for identifying pneumococci in 42 patients with community-acquired pneumonia. We considered the Gram's stain positive if a preponderant flora or more than ten Gram-positive lancet-shaped diplococci were seen per oil immersion (x1,000) field. These criteria were met in 18 (62%) of 29 specimens that actually contained pneumococci as determined by a positive quellung reaction, or culture on plates or in mice. The Gram's stain was negative in 11 of 13 specimens that did not contain pneumococci. Of the 20 specimens yielding positive Gram's stains, 18 contained pneumococci. A positive Gram-stained smear of sputum strongly suggests the presence of pneumococci, but will miss 38% of specimens containing pneumococci. Deviation from these criteria substantially reduces the overall accuracy of the test.

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A double-blind, prospective study over a 12-month period evaluated the effectiveness of cefazolin and cephalexin in reducing infection and morbidity in private patients undergoing vaginal and abdominal hysterectomy. Prophylactic antibiotics reduced febrile morbidity from 74.4% to 20.8% in the vaginal group and from 46.2% to 24.0% in the abdominal group. Serious postoperative infections such as pelvic abscess, pelvic cellulitis and abdominal wound infection were reduced from 11.5% to 0% in the abdominal group and from 32.6% to 2.1% in the vaginal group. The use of prophylactic antibiotics was of benefit in the perimenopausal and postmenopausal patient, as well as in the premenopausal patient, although, in some categories, the numbers were too small to be statistically significant.

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